Download Centene Inhales AirLogix in Latest DM Industry Acquisition URAC

Peter J. Solomon Company was pleased to act as the exclusive advisor to Centene Corporation. Managing Director J. Andrew Cowherd,
212-508-1610; [email protected], and Associate Director Ravi Sachdev, 212-508-1664; [email protected], led the transaction
for the firm.
Independent, timely business intelligence on disease and demand management
Volume 10, Number 15
August 10, 2005
Respiratory DM Firm Will Stay the Best-of-Breed Course
Centene Inhales AirLogix in Latest DM Industry Acquisition
Centene Corporation, a St.
Louis-based managed care organiza­
tion (MCO), has acquired AirLogix,
a best-of-breed disease management
(DM) firm focusing on respiratory
diseases.
The acquisition marks
Centene’s first entry into the DM
space, according to company
sources. The MCO historically has
provided Medicaid and Medicaidrelated programs to organizations
and individuals through governmentsubsidized programs. Centene says it
acquired Dallas-based AirLogix pri­
marily to expand the company’s
product line of specialty services,
which is managed by CenCorp
Health Solutions, a wholly owned
subsidiary of Centene.
Under the terms of the agree­
ment, Centene paid about $35 mil­
lion in cash for AirLogix. The deal
provides for additional financial con­
siderations of up to $5 million if
AirLogix achieves certain undis­
closed performance criteria. Centene
estimates that the acquisition will
initially generate annual revenues of
about $18 million for the firm but
will have a nominal earnings impact
on the MCO in 2005.
Michael Neidorff, Centene’s
chairman and chief executive officer,
says the acquisition of AirLogix was
made to support the company’s strat­
egy to build a multi-tiered, integrated
healthcare enterprise that will enable
the firm to consistently manage
healthcare costs on a sustainable and
long-term basis. In particular, the
combination of AirLogix’s DM
experience and Centene’s financial
strength will allow Centene to better
serve its expanding Supplemental
Security Income membership, a pri­
mary market segment for the firm,
while supporting AirLogix’s existing
customer base, he says.
Susan Riley, chief executive
officer of AirLogix, says the firms
strong track record of posting suc­
cessful financial and clinical out­
comes has made it a prime acquisi­
URAC Targets Outcomes, Care
Coordination in New DM Standards
Greater emphasis of disease
management (DM) outcomes meas­
urement methods and coordination
of care management services beyond
DM programs are two of several key
proposed changes included in the
second generation of URAC’s DM
accreditation standards.
URAC has released the draft
standards for public scrutiny and is
inviting comments on them by DM
organizations and others in the
healthcare community by August 25.
The revisions to URAC’s DM
accreditation standards are the first
to be made to the standards since
they were first introduced in final
form in April 2002 (DMN, 4/25/02,
p. 1). The changes in the second
generation of standards were made
largely to reflect transformations
that have occurred in the DM land­
scape in the last three years, accord­
ing to John DuMoulin, vice presi­
dent of government relations and
continued on page 4
tion target in recent years. “The main
reasons for being acquired are sim­
ple,” she tells DM News. “We were a
privately held company that never
had plans to go public, so an acquisi­
tion/merger was a natural evolution
of the business. We were growing
our top line by 40 percent year over
year, so we have been profitable and
attractive to potential buyers. Our
investors are very pleased.”
Riley also says the acquisition
gives the niche DM firm additional
resources that will enhance its ability
to manage the health concerns of
people with chronic respiratory dis­
eases such as chronic obstructive
pulmonary disease and asthma on a
much larger scale than it has been
able to in the past, particularly with
the Medicare market. “We know that
we have a unique approach in the
industry and wanted the resources
and size to take that approach to as
many people as possible,” she
explains. “We believe strongly that
one of the reasons we did not receive
continued on page 4
IN THIS ISSUE
Study Casts Doubts on DM’s ROI
Claims .......................................2
CMS Picks Health Hero for
Medicare DM Demonstration ...2
First Medicare Health Support
Programs Take Flight .............3
Canadian DM Data Project Could
Have Benefits South of the
Border .......................................7
DM News Briefs .......................8
A U G U S T
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Study Casts Doubts on DM’s ROI Claims
Despite the many claims of pos­
itive returns on investment (ROIs)
being made by disease management
(DM) organizations, the evidence of
the economic impact that DM pro­
grams are having is scarce, accord­
ing to researchers from Cornell
University and Thomson Medstat.
Their review of 44 studies ana­
lyzing the economic impact and
ROIs for DM programs revealed
mixed results for programs targeting
depression, diabetes and asthma, but
positive ROIs for programs targeting
congestive heart failure and multiple
illnesses. (See Figure 1, page 3.)
“Our interest was in reporting
whether assumptions about the posi­
tive economic impact of DM pro­
grams correspond to actual results
from well-designed studies that used
rigorous methods,” explains chief
researcher Ron Goetzel, director of
the Institute for Health and
Productivity Studies at Cornell and
vice president of consulting and
applied research at Ann Arbor, Mich.­
based Thomson Medstat. “There was
also a desire to inform public policy
experts about private sector innova­
tions in DM, and to learn whether
these innovations might hold promise
for Medicare and Medicaid patients.”
The project sheds light on DM
ROIs, but it does not provide con­
clusive findings about whether they
are predominantly positive or nega­
tive because relatively few econom­
ic analyses have been conducted,
says Goetzel. Making things more
difficult, many of the studies that
have been done have involved a
small universe of subjects, and the
DM programs that were analyzed
varied significantly in format, he
adds. “Overall, there has been little
scientifically rigorous research con­
ducted to determine the financial
impact of disease management,”
Goetzel says. “That’s a concern,
because companies and government
agencies have increasingly adopted
DM to control the cost of care for
individuals with chronic medical
conditions -- a minority of the pop­
ulation responsible for a majority of
healthcare spending.”
In the study, Goetzel and his
research team found that:
• The cost of DM programs for
congestive heart failure averaged
$1,399 per participant, and savings
averaged $3,884. The average ROI,
achieved in a little less than a year,
was $2.78 in savings per dollar spent
on the program. Four of the five
studies that used the optimal research
design produced a positive ROI.
• Many of the studies that
looked at DM programs for asthma
showed savings, but only two of the
better-designed studies delivered
enough savings to produce a positive
ROI and these studies covered very
few cases.
• The results for diabetes were
too variable to provide conclusions.
• Among programs managing
patients with multiple diseases, the
ROI ranged from $4.37 to $10.87 in
continued on page 3
CMS Picks Health Hero for Medicare DM Demonstration
The Centers for Medicare and Medicaid Services (CMS)
has selected a consortium of healthcare organizations led by
Health Hero Network to demonstrate how physicians can use
home health monitoring technology to help Medicare beneficiaries with chronic illness lead better lives while reducing costs
for Medicare and its beneficiaries.
Joining Health Hero Network in the consortium are the
American Medical Group Association, Bend Memorial Clinic
in Bend, Ore., and Wenatchee Valley Medical Center in
Wenatchee, Wash. The organizations have named their
project ACCENT -- Advancing Chronic Care through EHealth Networks and Technologies.
ACCENT is one of six demonstration projects that
CMS awarded as part of its Care Management for HighCost Beneficiaries Demonstration, which will test the ability
of direct-care provider models to coordinate care for highcost/high-risk Medicare beneficiaries by providing them with
clinical support beyond traditional settings to manage their
diseases and illnesses (DMN, 12/10/04, p. 2). Health Hero
joins RMS Disease Management as the only DM-related
firms to receive project awards under the demonstration
(DMN, 7/10/05, p. 8).
As with other DM-related firms participating in CMS’
planned and ongoing care coordination and DM demonstrations and programs, Health Hero and RMS will have the
opportunity to showcase the financial and quality of life benefits that DM programs can produce for Medicare fee-forservice (FFS) beneficiaries.
In the ACCENT project, Health Hero Network’s Health
Buddy home health monitoring system will support physicians
at medical groups in Oregon and Washington in coaching and
2
D I S E A S E
monitoring high-cost Medicare patients to help them stay
healthy and out of the hospital. “Doctors and patients, supported by technology, will work together to transform how we
care for people with complex chronic illness,” says Steve
Brown, president and chief executive officer of Mountain View,
Calif.-based Health Hero Network. “We’ve helped improve the
quality of life for thousands of veterans through our work with
the Veteran’s Administration. We’re excited about having a
similar impact on the lives of thousands of other American
seniors in Medicare.”
ACCENT has developed a technology-based care management process that it will use to care for up to 2,000
patients with congestive heart failure, diabetes, chronic
obstructive pulmonary disease or any combination of those
diseases. The goals of the project are to demonstrate improvements in quality of life and care for enrolled patients and a
minimum 5 percent net savings in Medicare costs of caring for
those patients. ACCENT organizations and all other awardees
under the demonstration will receive a monthly fee for each
beneficiary participating in the program to cover their adminis­
trative and care management costs. The three-year demon­
stration program is scheduled to begin in January 2006.
While enrolled in the demonstration, patients will be
given a Health Buddy home health monitoring appliance,
which physicians and nurses will use to coach patients on
preventive behaviors. The caregivers at the two medical
groups will then track patients using the Health Buddy sys­
tem’s web-based software to give them immediate data they
can use to spot problems early and, therefore, prevent crises
that could lead to unnecessary ER visits and hospital stays.
continued on page 6
M A N A G E M E N T
N E W S
A U G U S T
ROI continued from page 2
savings per dollar spent on these pro­
grams over an average of 1.4 years.
• DM programs targeting
depression consistently cost more -­
about $500 more a year -- than they
saved in direct medical costs.
However, these programs may deliv­
er a positive ROI if the impact on
patients’ day-to-day functioning,
absenteeism and overall productivity
is factored in.
Although it is clear that DM
programs can deliver significant
health benefits, employers and health
plans still need a sound business case
to continue offering these programs,
Goetzel believes. “More and better
research on the business case is
required,” he says.
Although Goetzel’s research
team did not intend to identify ingre­
dients of successful DM programs,
their review uncovered several
themes and strategies common to
successful programs that DM organi­
zations may find useful in their plan­
ning and operations:
• Offering individualized and
personalized risk-reduction counsel­
ing to those at highest risk.
• Developing appropriate clini­
cal guidelines based on the best sci­
entific evidence and updating them
as needed.
• Educating and involving physi­
cians and other providers on effective
implementation of these guidelines.
• Conducting repeated evalua­
tions.
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• Sharing results with providers
and patients.
• Leveraging information sys­
tems to identify patients for interven­
tion and measure clinical and finan­
cial outcomes.
• Providing “self-management”
education to teach patients problemsolving skills.
• Using organizational change
interventions, including the use of
separate clinics devoted to preven­
tion, planned care visits for preven­
tion, patient reminders and nonphysician staff to carry out specific
prevention activities.
• Effectively screening and
triaging patients into risk-specific
interventions.
• Using tailored materials
founded on behavior change theory.
• Using goal setting by patients.
The complete study findings
appear in the summer issue of
Health Care Financing Review and
are available online at cms.hhs.gov/
review/05summer.
Contact: David Wilkins,
Medstat, (734) 913-3397,
[email protected]. • Figure 1: Summary of DM ROI
Analysis for Selected Diseases
Average Per Participant
Cost and Savings
Disease
State
Asthma
Average
ROI
Total
Benefits/
Costs
Number
Avg. Sample
Size for
Intervention
Avg.
Evaluation
Period (Yrs.)
Cost
Savings
2
5
2
3
12
34
149
1471
144
449
1.0
2.3
1.1
0.8
1.3
$ 292.54
525.10
—
256.36
268.50
$ 1,067.74
(98.48)
557.29
1,390.64
729.30
3.65
(0.19)
NA
5.42
2.72
RCT(A)
RCT(B)
CBA
Pre-Post
Total
4
1
4
3
12
92
49
314
226
170
0.7
1.5
0.6
0.6
0.9
$ 464.50
1,190.00
1,018.00
2,715.15
1,399.22
$ 1,700.25
15,500.00
1,490.09
8,461.75
3,884.03
3.66
128.90
1.46
3.12
2.78
RCT
CBA (A)
CBA (B)
Pre-Post
Total
4
1
1
2
8
608
3,118
732
3,585
2,011
2.1
2.0
5.0
0.9
2.5
$1,862.33
580.50
—
—
610.71
$(1,013.25)
1,294.32
817.50
637.50
434.02
(0.54)
2.23
NA
NA
0.71
Study
Design
RCT (A)
RCT (B)
CBA
Pre-Post
Total
CHF
Diabetes
Notes: ROI is return on investment. RCT is randomized clinical trials. CBA is controlled,
before and after study design. NA is not applicable.
Source: Return on Investment in Disease Management: A Review, Health Care Financing
Review, Summer 2005.
First Medicare Health Support Programs Take Flight
The nation’s first Medicare
Health Support (MHS) programs
officially began operations on August
1 in Maryland/Washington, D.C.,
and Oklahoma.
The new three-year voluntary
pilot programs, being administered by
Nashville, Tenn.-based American
Healthways in Maryland and
Washington, D.C., and by LifeMasters
Supported SelfCare in Oklahoma, will
serve up to 20,000 fee-for-service
Medicare beneficiaries in each area.
Under the MHS programs, the two
disease management (DM) firms will
provide Medicare beneficiaries suffer­
ing from diabetes and congestive heart
failure (CHF) with health information,
education and special services to help
them take better care of their individ­
ual health needs and adhere to their
physician’s plan of care.
American Healthways’ program
will offer self-care guidance and sup­
port to chronically ill beneficiaries to
help them manage their health,
adhere to their physicians’ plans of
care, enhance the patient-physician
relationship, and ensure that benefi­
ciaries seek and obtain Medicarecovered benefits that will help reduce
their health risks, according to Kriste
D I S E A S E
Goad, a spokesperson for American
Healthways. Beneficiaries who agree
to participate will receive regular
phone calls from a team of RNs, reg­
ular health information mailings and
on-site nurse visits to beneficiaries in
long-term care facilities, she says.
The program’s managers and
caregivers also will apply real-time
data and customized reports to help
track patient health information and
progress toward specific goals
between office visits, Goad adds.
The program also features a dedicat­
ed program manager to help identify
continued on page 6
M A N A G E M E N T
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3
A U G U S T
Centene continued from page 1
a Chronic Care Improvement Project
was due to our being small with a
corresponding balance sheet. We
want the Centers for Medicare &
Medicaid Services to know that we
can handle the scale and the financial
risk associated with these programs
and demonstrate that our approach is
ideal for the Medicare population.”
Although AirLogix is now part
of a larger organization with a stated
strategic goal of creating a multi­
tiered entity, Riley expects AirLogix
to stay the course with its best-of­
breed focus on respiratory diseases.
“I believe that being a DM company
with a single disease focus did limit
us from a market size perspective to
some degree -- the size of the respi­
ratory disease market is, of course,
much smaller than that of the [total]
chronic disease, wellness and pre­
vention market. But we will always
remain true to the best-of-breed
model that provides deep interven­
tion, including home visits when
appropriate, to optimally impact a
person living with chronic illness.
We will not veer from our proven
model.”
Riley believes there is “ample
business” for both best-of-breed and
one-stop shops in the DM space. “I
truly wish we would stop trying to
put the business into an either/or sit­
uation where one will ultimately win
out,” she tells DM News. “It is not
URAC continued from page 1
product development for URAC.
The enactment of the
Medicare Modernization Act of
2003 with its Medicare Health
Support programs [formerly
Chronic Care Improvement
Programs], the call for greater
accountability in DM outcomes
measurement, a surge in consumerdirected healthcare, and the imple­
mentation of the HIPAA privacy
and security measures are four
prime examples of major system
changes that have occurred since
URAC’s DM standards first came
on the scene, DuMoulin says.
How well a DM organization
coordinates care beyond their bor­
ders to other healthcare programs
and organizations during a patient’s
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good for our customers, our patients
or the industry to make every model
the same. There are different
approaches for different needs.”
For example, an employer may
be comfortable with a very “light
touch” model that uses only tele­
phonic intervention to interact with a
participant, while a government
payer source may be more interested
in a streamlined approach that reach­
es all the way into the communities
and patients’ homes to achieve the
desired outcomes, she explains. “In
all areas of healthcare, there are gen­
eralists and specialists -- physicians,
hospitals, pharmaceuticals, home
health -- all of these sectors have
both approaches. That is because of
the vast array of different needs to be
met. One size simply cannot fit all in
healthcare and disease/population
management, nor should it.”
Riley believes Centene recog­
nized this when it chose to acquire
AirLogix. “Centene acquired us
because of our DM capabilities. They
view us as a platform from which to
launch many new products and serv­
ices. We feel honored. They currently
have some disease management pro­
grams in their local markets, and we
will be identifying ways to incorpo­
rate the best practices of all.”
Centene sees AirLogix’s servic­
es as a proven way to control their
medical management costs internally
as the DM firm provides services to
their health plans, according to Riley.
As part of Centene’s specialty prod­
ucts division, AirLogix will join a
behavioral health company, a nurse
line and a prescription compliance
company in this division, she says.
“We anticipate working closely with
the other companies to complement
our suite of services and assist them
in growth,” Riley says. “While pro­
viding services for Centene plans,
we will also continue to pursue com­
mercial, Medicaid managed care,
Medicare Advantage and fee-for­
service opportunities in the market as
we always have.”
Riley says she will remain chief
executive officer of AirLogix and the
rest of the DM firm’s management
team also will remain in place. The
only major change she expects to see
as a result of the acquisition is more
business for AirLogix. “We antici­
pate only growth, so do not expect
any changes to our employees’ status
other than much more opportunity as
we grow the business. [Centene] rec­
ognizes our superior performance in
disease management and wants us to
build on those results. We couldn’t
have asked for a better outcome to
our years of hard work in a difficult
industry.”
Contact: Robert Schenk,
Centene Corporation, (314) 725­
4477, [email protected]; Susan
Riley, AirLogix, (214) 576-2067, sri­
[email protected]. • transition of care is a new point of
emphasis in URAC’s standards,
according to Annette Watson, a vice
president for URAC. In Standard 7,
URAC is now proposing that a DM
program establish and implement
policies and procedures for coordi­
nation of services with DM pro­
gram participants and other healthcare programs and organizations,
including procedures for communi­
cating with those programs and
organizations when the program
participant is transferred to another
program or his or her DM benefit is
terminated.
Clarification of how DM pro­
gram performance requirements are
established and measured is another
key enhancement to the proposed
standards, says Karen Fitzner, direc­
tor of research and program develop­
ment for the Disease Management
Association of America (DMAA),
who served on URAC’s DM stan­
dards review committee. For exam­
ple, proposed Standard 2 would
require DM practices for each clini­
cal condition to be reviewed by a
clinical content expert with expertise
in the relevant clinical condition.
“These new revised standards
encourage more attention to proper
research methods and study design
that will benefit the disease man­
agement community as well as
patients with chronic illnesses,”
Fitzner says. “The evidence-based
focus will also enhance care for
those with chronic illness.”
Among the other major pro-
D I S E A S E
continued on page 5
M A N A G E M E N T
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A U G U S T
URAC continued from page 4
posed changes of note in URAC’s
draft DM accreditation standards:
• Two new definitions have
been added to the glossary, for “out­
come” and “valid.” (See sidebar.)
• Recognizing the trend toward
consumer-directed care, Standard 5,
formerly labeled Shared DecisionMaking, has been renamed
Consumer Decision-Making, and
several other references to “shared”
throughout the standards now spec­
ify that the “consumer” is the pri­
mary focus of the standard.
• Standard 16, which formerly
addressed stratification and assess­
ment of eligible DM program par­
ticipants, has been split into two
separate standards, with Standard
16 addressing stratification and a
new Standard 17 addressing assess­
ment. (See sidebar.) This addition
raises the total number of URAC’s
DM accreditation standards to 23
from the original 22.
URAC is encouraging broad
public comment on its proposed
DM accreditation standards through
August 25 using an online com­
ment form available on the organi­
zation’s web site, urac.org. The
Washington, D.C.-based organiza­
tion also will accept comment by
email ([email protected] with
the subject line Comments -- DM
Standards), standard mail or fax.
To ease reviewers’ understand­
ing of the changes, URAC has
developed a crosswalk between the
two versions. It is also available on
the organization’s web site.
The standards are designed to
accredit the full spectrum of organi­
zations providing DM, Watson
says. To encourage innovation in
DM, the standards are not diseasespecific, which differentiates them
from those of rival accrediting
organizations such as NCQA and
JCAHO, she explains. They apply
to all types of organizations provid­
ing DM services, including health
plans, stand-alone DM organiza­
tions and medical management
organizations, Watson says.
“That is what sets URAC’s
disease management accreditation
apart,” she tells DM News.
“Companies offering a wide array
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of disease management services,
including leading-edge programs in
areas such as childhood obesity,
behavioral health or end-stage renal
disease, can benefit from URAC’s
disease management accreditation.
It’s not for diabetes or asthma serv­
ices alone.”
Watson says URAC shaped
many of its DM accreditation stan­
dards using DMAA’s definition of
DM as a rough template. URAC
adopted DMAA’s definition with its
initial set of standards to promote
consistency in the industry, so
organizations that meet that defini­
tion of DM are eligible to apply for
accreditation by URAC, she says.
“URAC’s disease manage­
ment accreditation does not make
what we believe to be confusing
distinctions between what type of
organization is providing the serv­
ices,” Watson explains. “URAC is
most interested in ensuring that
disease management services in
any setting are held to the same
rigorous standards.”
Contact: Annette Watson, URAC,
(202) 216-9010, [email protected];
Karen Fitzner, DMAA, (202) 778­
3297, [email protected]. • URAC’s Draft DM Standards Add New Definitions
URAC’s proposed disease management (DM) accreditation standards include
two new definitions to the standards’ glossary that reflect the greater emphasis on DM
program measurement.
• Outcome. A measure that indicates the result of the performance (or nonperfor­
mance) of a program, service or intervention. The evaluation methods may include clin­
ical, financial, utilization, economic, quality and humanistic outcomes (e.g., patient or
provider satisfaction).
• Valid. Based on accepted principles of study design, research methodology
and statistical analysis.
Source: URAC, Disease Management Standard Version 2.0, Public Comment Draft
Proposed Standards Separate Stratification,
Assessment of Eligibles
DM Standard 16: Stratification of Eligible Consumers
The disease management program implements a process for stratifying a popula­
tion of eligible consumers into groups that:
• Defines criteria for each level of stratification and identifies at which levels eligi­
ble consumers will receive an individual assessment.
• Is based on written criteria that define data sources for conducting the stratifica­
tion process.
• Includes an initial stratification of eligible consumers that can be used to priori­
tize contacts with consumers.
• Is conducted according to timelines that require the disease management pro­
gram to complete the stratification and assessment processes within a specified period
of time after identification of eligible consumers.
• Ensures that co-morbid conditions are identified, documented. and considered
in the assignment of interventions.
• Includes periodic restratification, which must be at least annual.
• Incorporates evidence-based tools where available.
DM Standard 17: Assessment of Eligible Consumers
The disease management program implements process for conducting interac­
tive individual consumer assessment for consumers identified in Standard 16:
• Identifies tools and methods to be used for conducting individual consumer
assessments that are specific to the consumer’s clinical condition.
• Documents the results of individual assessments conducted.
• Includes a mechanism by which stratification level and associated interventions
can be adjusted based on individualized assessment or other data.
• Includes periodic reassessment, which must be at least annual.
• Incorporates evidence-based tools where available.
Source: URAC, Disease Management Standard Version 2.0, Public Comment Draft
D I S E A S E
M A N A G E M E N T
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5
A U G U S T
Health Hero continued from page 2
Donald Fisher, president of
Alexandria, Va.-based AMGA,
applauds CMS’ willingness to look
at creative approaches to managing
high-risk patients with chronic dis­
ease and conditions. “The ACCENT
Project will demonstrate that doctors
and patients with severe chronic ill­
ness, supported by information tech­
nology, can establish a new partner­
ship to provide exceptional preven­
Medicare continued from page 3
6
2 0 0 5
tive care for patients in their homes
and keep them healthier and living
independently longer while reducing
costs,” he says.
In addition to its latest DM
demonstration award, Health Hero
Network is participating as a sub­
contractor in two Medicare Health
Support projects serving up to
180,000 additional Medicare bene­
ficiaries patients around the coun­
try. Those beneficiaries will receive
chronic care improvement services
through DM organizations and
health plans that Health Hero is
working with.
Contact: Kathy Goodman,
Health Hero Network, (650) 559-1034,
[email protected]; Julie
Sanderson-Austin, American Medical
Group Association, (703) 838-0033,
[email protected]; Cynthia
Mason, CMS, (410) 786–6680, cmhcb­
[email protected]. • Figure 1: Program Features of
Medicare Health Support Programs
patients who are not following rec­
ognized standards of care, she says.
LifeMasters’ MHS program will
make use of the DM firm’s supported
self-care model that centers on edu­
cation, medication compliance and
behavior change, according to
Barbara Gideon, a spokesperson for
the Irvine, Calif.-based DM firm. The
program will also establish a team of
local and call center-based nurses,
physicians, pharmacists and health
educators in Oklahoma to administer
the program, according to Gideon. In
addition, it will emphasize physician
communication by developing cus­
tomized care plans, alerts and deci­
sion support applications and by eas­
ing physicians’ access to patient care
records and biometric monitoring
data, she says. And as part of the
physician outreach component of the
MHS program, LifeMasters also will
conduct in-person orientations about
the program for high-volume physi­
cian practices, Gideon says.
With the MHS programs, CMS
hopes to improve the health and qual­
ity of life of Medicare beneficiaries
and to reduce the amount of state and
federal money spent on costly, yet
avoidable, medical procedures, hospi­
talizations and emergency room visits
by helping beneficiaries actively pre­
vent complications that can arise
from chronic diseases.
The programs are two of nine
MHS programs being launched by
CMS in various regions of the coun­
try for about 180,000 beneficiaries
with diabetes and CHF. Although all
of the MHS programs will target pri­
marily those two diseases, how they
go about managing them will be
continued on page 7
1 0 ,
Chronic Care
Improvement
Organization
AETNA Inc.
American
Healthways
CIGNA
Health Dialog
Humana
LifeMasters
McKesson
Visiting Nurse
Service–
EverCare/Unit
ed HealthCare
Services
XL Health
Geographic
Areas Served
Program Features
• Advance Practice Nursing Program for home health and nursing homes
• Customized care plans
• Caregiver education
• Blood pressure monitors and weight scales provided based on participant need
• Physician communication
• Physician web access to clinical information
• 24-hour nurse line
• Personalized care plans
• Direct-mail and telephonic messaging
• Supplemental telephonic coaching
• Gaps in care generate physician prompts
• Intensive case management services as necessary
• Remote monitoring devices (weight, blood pressure and pulse) based on participant need
• Physician web access to clinical information
• Physician communication
• 24-hour nurse line
• Personalized plan of care
• Telephonic nurse interventions
• Oral and written communication in addition to telephonic coaching
• Home monitoring equipment (weight, blood pressure and glucometers) based on participant need
• Intensive case management for frail elderly and institutionalized participants, as required
• Data exchange with physicians
• 24-hour nurse line
• Personal health coaches develop individual care management plans
• Health education materials (web-based, faxed or mailed)
• In-home biometric monitoring
• Behavioral health case management and intensive case management as needed
• Data exchange with physicians,
• Active involvement of other community agencies
• 24-hour nurse line
• Trademarked Personal Nurse program model
• Group education and support sessions
• Biometric monitoring equipment, including glucometers and weight scales as necessary
• Core telephonic support supplemented with RNs, social workers and pharmacists in the field
interacting with providers and beneficiaries with complex needs
• Data exchange with physicians
• On-site meetings with physicians and CME programs
• Physician web access to clinical information
• Electronic medical recordkeeping systems will be piloted in five small physician-group practices
• Active involvement of other community agencies
• 24-hour nurse line
• Single nurse as primary contact for beneficiary
• Supported self-care model including education, medication compliance, behavior change
• Home visits as appropriate
• Team of local and call center-based nurses, physicians, pharmacists, and health educators
• Digital weight scale and blood pressure monitors
• Physician communication including customized care plans, alerts, decision support applications;
access to patient care record and biometric monitoring data
• Physician outreach includes in-person orientation for high-volume physician practices
• Physician web access to clinical information
• Active involvement of other community agencies
• 24-hour nurse line
• Extensive physician involvement, including on-site staff support
• Data exchange with physicians,
• Physician web access to clinical information
• Telephonic outreach
• Mail, fax, workbooks
• Remote monitoring and biometric equipment for selected high-risk participants
• Pharmacist review of medications and collaboration with physicians
• Management of long-term care residents and intensive case management, including end-of-life
• 24-hour nurse line
• Home health agency leading outreach in community
• Management of high-risk participants who require extensive in-home management
• Telephonic outreach and health risk assessments
• Use of SmartCards to use at physician visits and hospital admissions to track service use and convey
embedded information to providers
• Physician web access to clinical information
• Active involvement of other community agencies
• 24-hour nurse line
• Biometric monitoring including glucometers and weight scales as necessary
• RNs, social workers, and pharmacists in the field, interacting with providers and beneficiaries with
complex needs
Source: Centers for Medicare & Medicaid Services
D I S E A S E
M A N A G E M E N T
N E W S
Selected
Chicago
Counties
Maryland and
Washington,
D.C.
Northwest
Georgia
Western
Pennsylvania
Central and
South Florida
Oklahoma
Mississippi
Brooklyn and
Queens, N.Y.
Selected
Counties in
Tennessee
A U G U S T
Medicare
continued from page 6
largely up to each program. Details
about the scope and plan of opera­
tions for the nine MHS programs has
been sketchy up to this point, but a
recent CMS transmittal shed consid­
erable light on who plans on doing
what.
In a July 22 transmittal to
Medicare fee-for-service providers,
CMS detailed the features that each
MHS program is expected to
include. (See Figure 1, page 6.) All
1 0 ,
2 0 0 5
MHS programs will make use of the
standard 24-hour nurse call lines that
are the staple components of most
DM programs today, but several pro­
grams will call upon some innovative
tools and strategies.
For example, Visiting Nurse
Service of New York, in partnership
with United HealthCare Services
Inc.-Evercare, will use “smartcards”
at physician visits and hospital
admissions to track service use and
convey embedded information to
providers. Meanwhile, Humana will
pilot test an electronic medical
record (EMR) system in five small
physician-group practices to assess
whether and to what extent an EMR
system can benefit DM programs for
Medicare beneficiaries.
Contact: Kriste Goad, American
Healthways, (615) 263-7524,
[email protected];
Barbara Gideon, LifeMasters
Supported SelfCare, (650) 829-5287,
[email protected]. • Canadian DM Data Project Could Have Benefits in U.S.
Four provinces in Canada are
developing a novel chronic disease
management (DM) infostructure that
could hold lessons for DM providers
in the United States.
Called the Chronic Disease
Management Infostructure (CDMI)
initiative, the project is an undertak­
ing of the Western Health
Information Collaborative (WHIC), a
group of deputy health ministers that
is working together to explore col­
laborative opportunities with respect
to health infostructure initiatives.
Four Canadian provinces have com­
bined their efforts to assess their cur­
rent state of chronic DM (CDM),
develop business requirements and
define an information management
framework aimed at ensuring stan­
dardized information exchange of
clinical DM data. The four provinces
participating in the initiative are
British Columbia, Alberta,
Saskatchewan and Manitoba.
“The primary objective of this
initiative is to develop common data
standards and information exchange
protocols and provide support for the
implementation of these standards at
a regional and/or provincial level,”
says Michael Hurka, project director
of the CDMI initiative. “This will
promote the need for action on
advanced and complex components
of the electronic health record
(EHR), such as chronic disease man­
agement, concurrent with many
jurisdiction specific actions on EHR
building blocks such as registries,
diagnostic imaging and pharmacy.”
Hurka says developing and
implementing a chronic DM infos­
tructure is a key component of estab­
lishing an effective chronic DM pro­
gram nationally in Canada. And, if
successful, it will be a significant
accomplishment. “The success of the
development and integration of this
infostructure in four quite different
provinces, as part of a multi-jurisdic­
tional collaboration, is a major
achievement,” Hurka tells DM News.
To date, the project has deliv­
ered a current state assessment, busi­
ness requirements and an informa­
tion management framework,
according to Hurka. Current project
activities are focused on defining the
data standards for three specific
chronic conditions -- diabetes, hyper­
tension and chronic kidney disease.
“The definition of standards for
these three conditions is being done
in the context of a generic model for
chronic conditions,” Hurka explains.
“Even though the WHIC-CDM
Infostructure initiative is focusing on
these three specific conditions, there
is an expectation that the standards
and messages defined through this
project can be easily extended to
enable information exchange for
other chronic conditions.”
Those same standards and mes­
sages could also extend south to ben­
efit DM programs in the United
States, Hurka adds.
Message definition for the proj­
ect is being done using the latest ver­
sion of HL7, an international stan­
dard for health information
exchange. “It is anticipated that by
using this widely accepted interna­
tional standard for CDM data
exchange, the standards developed
D I S E A S E
by the project can be positioned for
broader acceptance and uptake,”
Hurka says.
The content of the data stan­
dards and the HL7 message specifi­
cations are expected to be finalized
shortly, and the CDM infostructure is
expected to be implemented by
March 2006, according to Hurka.
Over the next few months, the proj­
ect will also be working with the
electronic medical record (EMR)
software vendor community in
Canada to understand their collective
readiness to implement HL7 mes­
sages, he adds. “Once the message
specifications are completed, they
will be widely shared with the EMR
vendor community,” Hurka says.
“Vendor engagement is important
because as more software products
are able to support standardized elec­
tronic message exchange, the ability
to share chronic disease data
between increasing numbers of care
providers and locations will be
enabled.”
Clinical software solutions and
the messages they send and receive
will be key components of the
CDMI, Hurka says. Each province
has selected two sites for initial
implementation of CDM software.
Provinces and health authorities will
be working with their respective
service providers and/or vendors to
ensure that their applications are
compliant with the CDM data stan­
dards and are capable of exchanging
this data via HL7 messages, he says.
“Real-time access to relevant
chronic disease data will assist pri­
continued on page 8
M A N A G E M E N T
N E W S
7
A U G U S T
Canada continued from page 7
mary health care teams in providing
care to individuals with chronic con­
ditions,” Hurka says. “The impact on
the EMR vendor community will be
the opportunity to incorporate stan­
dardized messaging that has been
developed collaboratively into their
products using HL7.”
In addition, he says, “the project
1 0 ,
2 0 0 5
is expected to have a positive impact
on clinicians, who will begin to see
the capability to exchange CDM data
in a standardized way. This is a criti­
cal prerequisite in building towards
an EHR that will incorporate chronic
disease information and will facilitate
the exchange of information across
Canada. Common standards and
messaging that supports primary
healthcare strategies will encourage
the development of interoperable
EHRs and the capability to put
appropriate clinical information in
the hands of care providers who need
it, when they need it.”
Contact: Michael Hurka, WHIC
Chronic Disease Management
Infostructure Initiative, (780) 415­
1412, [email protected]. • DM NEWS BRIEFS
Health Dialog picked for NHS
project. England’s National Health
Service (NHS) has selected Health
Dialog Services Corporation to partici­
pate in NHS’ Predictive Risk Project.
The project will address the rising
healthcare costs associated with chron­
ic conditions in Britain. Health Dialog
will work with New York University to
develop predictive modeling algorithms
that will be used to identify patients at
high risk of emergency hospital admis­
sion. The project is planned to be com­
pleted by January 2006. The NHS for­
mulated the Predictive Risk Project to
help identify patients at highest risk of
future emergency admission in order to
ensure that case management services
are targeted most effectively and that
people receive appropriate healthcare
interventions at the right time. The risk
prediction system will be used by
Primary Care Trusts, which are physi­
cian organizations under the NHS that
are responsible for managing primary
care in a given geographical area.
Contact: Palmer Reuther,
Racepoint Group Inc., (781) 487-4606,
[email protected].
will be implemented during the first
quarter of 2006. Collectively, the new
employer, health plan and biopharma
accounts and the additional covered
lives from the expanded accounts will
represent approximately 375,000 addi­
tional covered lives for the DM firm.
Contact: Stephen Mengert,
Matria Healthcare, (770) 767-4500,
[email protected].
Healthways signs deal with
Alameda. American Healthways has
signed a new, two-year agreement to pro­
vide its StatusOne high-risk care man­
agement program to Medi-Cal benefici­
aries of Alameda Alliance, a Californiabased, not-for-profit health plan serving
more than 91,500 Alameda County resi­
dents. The new agreement begins Sept. 1,
2005. Under the arrangement, American
Healthways will support a specific group
of beneficiaries of Alameda Alliance’s
managed Medicaid program, Medi-Cal,
who are at highest risk for acute and
high-cost health episodes.
Contact: Kriste Goad, American
Healthways, (615) 263-7524,
Matria inks seven new deals.
Matria Healthcare Inc. has signed
seven new DM accounts, say officials
with the Marietta, Ga.-based DM firm.
The company also has expanded the
scope of contracts with three existing
customers. Matria’s seven new con­
tracts are with five self-insured
employers, one biopharma company
and one regional health plan. The three
awards of expanded business are with
self-insured employers. By policy,
Matria does not disclose the names of
its customers. Two of the seven new
accounts have been implemented, and
Matria expects to implement services
for the other five new accounts during
the third and fourth quarters of 2005
and the first quarter of 2006. One of
the three expanded accounts has also
been implemented, and the other two
8
D I S E A S E
[email protected].
Independence Blue Cross adds
Accordant’s DM programs to portfo­
lio. Philadelphia-based Independence
Blue Cross (IBC) has expanded its DM
offerings to plan members to include
DM programs for uncommon complex
conditions such as rheumatoid arthritis
and multiple sclerosis. The expansion
is the result of an agreement between
IBC and Accordant Health Services
under which the Greensboro, N.C.­
based DM firm will add its DM pro­
grams to IBC’s existing portfolio of
DM services. IBC began providing its
members and physicians with the
expanded DM services last month.
They are expected to affect about
20,000 people in health plans adminis­
tered by IBC. IBC’s two-year old DM
initiative currently provides DM pro­
grams for coronary artery disease,
chronic obstructive pulmonary disease,
congestive heart failure and diabetes.
Contact: Liz Williams,
Independence Blue Cross, (215) 241­
2220. • ©Copyright 2005 National Health Information, LLC, P.O. Box 15429, Atlanta, GA 30333-0429;
phone (404) 607-9500; fax (404) 607-0095. Publisher: David Schwartz. Editor: Tony Sullivan, phone
(630) 665-7510; fax (630) 665-7580. Contributing Editor: Russell Jackson. Subscriptions cost $397 a
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